Question 1

During an admission assessment,the nurse notices that a male patient has an enlarged and rather thick skull.The nurse suspects acromegaly and would further assess for:

Accepted Answer

Acromegaly,caused by excessive secretion of growth hormone,manifests as an enlarged skull and thickened cranial bones.Patients will have elongated heads,massive faces,prominent noses and lower jaws,heavy eyebrow ridges,and coarse facial features.

Question 2

The nurse is performing an assessment on a 7-year-old child who has the following symptoms: chronic watery eyes,sneezing,and clear nasal drainage.The nurse notes the presence of a transverse line across the bridge of the nose,dark blue shadows under the eyes,and a double crease on the lower eyelids.These findings are characteristic of:

Accepted Answer

Chronic allergies often cause the development of characteristic facial features.These include blue shadows below the eyes,a double or single crease on the lower eyelids,open-mouth breathing,and a transverse line on the nose.

Question 3

During a well-baby checkup,the mother expresses concern that her 2-month-old infant is not able to hold her head up when she is pulled to a sitting position.Which of the following responses by the nurse is appropriate?

Accepted Answer

Head control is not achieved until 4 months,when the baby can hold the head erect and steady when pulled to a vertical position.

Question 4

A woman is at the clinic for a checkup and says,"My eyes have gotten puffy,and my eyebrows and hair have become coarse and dry." The nurse suspects:

Accepted Answer

Myxedema (hypothyroidism)is a deficiency of thyroid hormone that,when severe,causes a nonpitting edema or myxedema.The patient will have a puffy edematous face,especially around the eyes (periorbital edema);coarse facial features;dry skin;and dry,coarse hair and eyebrows.

Question 5

During the assessment of an infant,the nurse notes that the fontanelles are depressed and sunken.Which condition does the nurse suspect?

Accepted Answer

Depressed and sunken fontanelles occur with dehydration or malnutrition.

Question 6

During an examination of a female patient,the nurse observes lymphadenopathy and suspects an acute infection.Acutely infected lymph nodes would be:

Accepted Answer

Acutely infected lymph nodes are bilateral,enlarged,warm,tender,and firm but freely movable.

Question 7

The nurse has just completed a lymph assessment on a 60-year-old healthy female patient.The nurse knows that most lymph nodes in healthy adults are normally:

Accepted Answer

Most lymph nodes are not palpable in adults.The palpability of lymph nodes decreases with age.

Question 8

The physician has diagnosed a tracheal shift in a patient.The nurse is aware that this means that the patient's trachea is:

Accepted Answer

The trachea is pushed to the side that is not affected by an aortic aneurysm,a tumour,unilateral thyroid lobe enlargement,or pneumothorax.

Question 9

Which of the following findings during examination would indicate Paget's disease?

Accepted Answer

Paget's disease occurs more often in males and is characterized by bowed,long bones,sudden fractures,and enlarging skull bones that press on the cranial nerves causing symptoms such as headache,vertigo,tinnitus,and progressive deafness.

Question 10

The nurse suspects that a patient has hyperthyroidism,and laboratory data also indicate that the patient's T₄ and T₃ hormone levels are elevated.Which of the following would the nurse most likely find on examination?

Accepted Answer

T₄ and T₃ are thyroid hormones that stimulate the rate of cellular metabolism.With an enlarged thyroid,as in hyperthyroidism,you might expect to find tachycardia and diffuse enlargement (goitre)or a nodular lump.

Question 11

A patient is at the clinic because he has recently noticed that the left side of his mouth is paralyzed.He states that he cannot raise his eyebrow or whistle.The nurse suspects that he has:

Accepted Answer

With an upper motor neuron lesion (as with CVA),the patient will have paralysis of lower facial muscles,but the upper half of the face is not affected because of the intact nerve from the unaffected hemisphere.The person is still able to wrinkle the forehead and close the eyes.

Question 12

The nurse is preparing to auscultate a patient's enlarged thyroid for the presence of a bruit.A bruit is a:

Accepted Answer

If the thyroid gland is enlarged,auscultate it for the presence of a bruit,which would be indicated by a soft,pulsatile,whooshing,blowing sound heard best with the bell of the stethoscope.

Question 13

During an examination of a 3-year-old child,the nurse notes a bruit over the left temporal area.What should the nurse do?

Accepted Answer

Bruits are common over the skull in children under 4 or 5 years of age or in children with anemia.They are systolic or continuous,and are heard over the temporal area.

Question 14

A very concerned mother is at the clinic with her infant who has a large,soft lump on the side of his head.She tells the nurse that she noticed the lump about 8 hours after her baby's birth and that it seems to be getting bigger.One possible explanation for this is:

Accepted Answer

A cephalhematoma is a subperiosteal hemorrhage resulting from birth trauma.It is soft,fluctuant,and well-defined over one cranial bone.It appears several hours after birth and gradually increases in size.

Question 15

During the examination of a patient in her third trimester of pregnancy,the nurse notices that the patient's thyroid gland is slightly enlarged.No enlargement had been noted previously.The nurse suspects that:

Accepted Answer

The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

Question 16

While performing a well-child assessment on a 5-year-old,the nurse notes the presence of palpable bilateral cervical and inguinal lymph nodes.The nodes are approximately 0.5 cm in size,round,mobile,and nontender.The nurse suspects that this:

Accepted Answer

Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy.Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete,movable,and nontender.

Question 17

When examining children with Down's syndrome (trisomy 21),the nurse looks for the possible presence of:

Accepted Answer

With the chromosomal aberration trisomy 21,also known as Down's syndrome,head and facial characteristics may include upslanting eyes with inner epicanthal folds,a flat nasal bridge,a small broad flat nose,a protruding thick tongue,ear dysplasia,a short broad neck with webbing,and small hands with a single palmar crease.

Question 18

A visitor from Poland who does not speak English appears somewhat apprehensive while the nurse is examining his neck.He would probably be most comfortable if the nurse were examining his thyroid:

Accepted Answer

Examining this patient's thyroid from behind may be unsettling for him.It would be best to examine his thyroid using the anterior approach,asking him to tip his head forward and to the right.

Question 19

Which of the following is the best way to palpate the lymph nodes in the neck?

Accepted Answer

Use gentle pressure because strong pressure could push the nodes into the neck muscles.It is usually most efficient to palpate with both hands,comparing the two sides symmetrically.

Question 20

A mother who has brought her newborn infant for assessment tells the nurse that she has noticed that whenever her newborn's head is turned to the right side,the baby straightens out the arm and leg on the same side and flexes the opposite arm and leg.After confirming this on examination,the nurse would tell the mother that this is:

Accepted Answer

By 2 weeks,the infant shows the tonic neck reflex in the supine position with the head turned to one side (extension of same arm and leg,flexion of opposite arm and leg).The tonic neck reflex disappears between 3 and 4 months of age.

Quiz 14: Head and Neck, including Regional Lymphatic System